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Practical Instructions to fill in the questionnaire:
Just click once on the box you want to check to validate your choice. If by any chance you have made a mistake just click again on the box to clear your previous answer.

Localization of psoriasis plaques at the moment of the most severe flare: (do not fill-in if it is the first flare)

Yes

No

Unknown

Yes

No

Unknown

Yes

No

Unknown

Yes

No

Unknown

Arms

Legs

Thorax ant

Palms

Elbows

Upper Back

Folds

Soles

Forearms

Low Back

Scalp

Finger Nails

Thighs

Buttocks

Face

Toe Nails

Knees

Abdomen

Genitals

Appearance at the moment of the most severe flare:

Yes

No

Unknown

Chronic plaque-type

Guttate

Erythroderma

Pustular, Localized

Pustular,Von Zumbusch

* At the time of the first flare, the information needed to evaluate the phenotype is not available

** Erythroderma is defined as the involvement of 90% of the BSA is associated with thin scaling and erythema. (Generalised psoriasis being defined as the presence of classic psoriasis plaques in most body areas)

Triggering factors:

Yes

No

Yes

No

Koebner (mechanic aggressions)

Pregnancy

Change of seasons

Infectious disease(s)

Beta blockers

Weight gain

Antimalarial

Alcohol intake

Converting enzyme inhibitor

Smoking

Calcium channel blockers

Life events (stress, mourning…)

Lithium

Stop of systemic corticosteroids

NSAIDs

Hypocalcemia

Effects of environmental factors:

Sun

Worsening

Improvement

No Effect

Unknown

Sun + Sea

Worsening

Improvement

No Effect

Unknown

Associated comorbidities (determined by history &/or investigations):

Yes

No

Yes

No

Atopy

Gout

Diabetes ID

Lipid disorder

Diabetes NID

Skin cancer

Hypertension

Alcoholism

Liver disease

Tobacco addiction

Renal insufficiency

Vitiligo

HIV

Crohn

Obesity

Ischemic heart disease

Thyroid disease

Parathyroid disease

Other (please mention)

Joint manifestation : is there psoriatic arthritis?

Yes

No

Unknown

Presence of antigen HLA B27 ?

Yes

No

Unknown

The joint lesion :

Precedes skin Lesion

Goes together with the skin Lesion

Follows the skin Lesion

The joint lesion is :

Peripheral

Axial

Mixed

Specify affected joint(s):

Laboratory investigations:

Were laboratory investigations done?

Yes

No

Unknown

Values above the normal higher limits?

Yes

No

Yes

No

ALT

AST

Alkaline phosphatase

Cholesterol

LDL

TG

MCV -- (mean corpuscular volume)

Uric acid

Creatinine

Creatinine clearance

Urea

CRP

CBC

Serum Calcium

Serum Albumin

FBG

Psoriasis Score (calculated on the current psoriasis situation) Scale System

Erythema

0 – None

1 – Slight

Pinkish erythema, scarcely visible

2 – Moderate

Distinct pink erythema

3 – Severe

Vibrant red erythema

4 – Very Severe

Dark red erythema, mauvish

Infiltration

0 – None

Normal cutaneaous microrelief

1 – Slight

Discreet deterioration in non-palpable cutaneous microrelief

2 – Moderate

Deterioration in palpable cutaneous microrelief

3 – Severe

Distinct infiltration

4 – Very Severe

Thick plaque (marked raising of the plaque’s height)

Desquamation

0 – None

1 – Slight

Slender and occasional scales on fewer than 5% of lesions

2 – Moderate

Furfuraceous scales

3 – Severe

Micaceous scales

4 – Very Severe

Chalky scales

Pruritus

0 – None

No pruritus

1 – Slight

Localised temporary pruritus, scratching tic

2 – Moderate

Intermittent, localised but violent pruritus, lichenification

3 – Severe

Permanent, extensive, painful pruritus, interfering with social life

4 – Very Severe

Continuous, sleep-depriving, generalised and causing bleeding

Deterioration of Quality of Life

0 – None

1 – Slight

Easily overcome discomfort

2 – Moderate

Daily experienced discomfort

3 – Severe

Impact on the relationships with oneself and the others

4 – Very Severe

Major personal and social disability

Localization

Erythema

Desquamation

Infiltration

Pruritus

Quality of Life

Yes

No

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

Arms

Elbows

Forearms

Thighs

Knees

Legs

Upper Back

Low Back

Buttocks

Abdomen

Thorax ant

Folds

Scalp

Face

Genitals

Palms

Soles

Psoriasis severity evaluation

BSA

Localization

Number of nails affected

Quality of Life

Yes

No

0

1

2

3

4

5

6

7

8

9

10

0

1

2

3

4

Finger nails

Toe nails

Psoriasis Nail Involvement

Yes

No

Please check the box if none of the following treatments has been taken by the patient:
Otherwise, please specify in the table below the received treatments and response to the treatments:
1=Bad response , 2= Mediocre , 3= Good , 4= Excellent , 5= Unknown

Received treatments

Effectiveness

Tolerance

Most effective Treatment

Yes

No

0

1

2

3

4

5

0

1

2

3

4

5

(1 answer only)

Moisturizing

Topical Tar Preparation

Salicylic Acid Preparation

Dioxyanthranol

Topical corticotherapy

Topical Vit. D derivatives

Association Vit. D3 analogues + corticoids

Topical retinoids

Topical PUVA

Systemic PUVA

NB-UVB

BB-UVB

Systemic retinoids

Methotrexate

Cyclosporine

Leflunomide

Salazopyrin

Alternative medicine

Etanercept (Enbrel)

Adalimumab (Humira)

Infliximab (Remicade)

Ustekinumab (Stelara)

Secukinumab (Cosentyx)

Certolizumab pegol (Cimzia)

Others

No Effective Treatment

Follow up visits:

At months:

Psoriasis severity evaluation :

- BSA :

%

Psoriasis nail involvement :

Yes

No

Joint involvement :

Yes

No

Investigations :

Treatment :

- Current line :

- Response :

Effectiveness

0

1

2

3

4

5

Tolerance

0

1

2

3

4

5

At months:

Psoriasis severity evaluation :

- BSA :

%

Psoriasis nail involvement :

Yes

No

Joint involvement :

Yes

No

Investigations :

Treatment :

- Current line :

- Response :

Effectiveness

0

1

2

3

4

5

Tolerance

0

1

2

3

4

5

At months:

Psoriasis severity evaluation :

- BSA :

%

Psoriasis nail involvement :

Yes

No

Joint involvement :

Yes

No

Investigations :

Treatment :

- Current line :

- Response :

Effectiveness

0

1

2

3

4

5

Tolerance

0

1

2

3

4

5

At months:

Psoriasis severity evaluation :

- BSA :

%

Psoriasis nail involvement :

Yes

No

Joint involvement :

Yes

No

Investigations :

Treatment :

- Current line :

- Response :

Effectiveness

0

1

2

3

4

5

Tolerance

0

1

2

3

4

5

At months:

Psoriasis severity evaluation :

- BSA :

%

Psoriasis nail involvement :

Yes

No

Joint involvement :

Yes

No

Investigations :

Treatment :

- Current line :

- Response :

Effectiveness

0

1

2

3

4

5

Tolerance

0

1

2

3

4

5

At months:

Psoriasis severity evaluation :

- BSA :

%

Psoriasis nail involvement :

Yes

No

Joint involvement :

Yes

No

Investigations :

Treatment :

- Current line :

- Response :

Effectiveness

0

1

2

3

4

5

Tolerance

0

1

2

3

4

5

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